History

Patients may relay a history of the eye being struck by an object larger than the diameter of the orbital entrance. Fists, balls, or car dashboards are examples.

Patients may have no complaints. However, they may complain of vision loss or diplopia. The double vision is often vertical and worse with attempted up or downgaze.

Numbness (hypoesthesia) of the cheek and gum on the affected side may be present. Ecchymoses, ptosis (droopiness of the eyelid), and swelling around the eye may be noted.

The examiner should obtain a past ocular history to assess whether any loss of vision or diplopia is due to the present accident or was established prior to this incident.

Physical

A complete ocular evaluation is essential to ensure that no injury to the globe or optic nerve has occurred.

Visual acuity and pupils should be evaluated to ensure that no loss of vision or traumatic optic neuropathy has occurred.^[5]

The examiner should evaluate extraocular movements and document any restriction or palsy.

A complete slit lamp evaluation and measurement of intraocular pressures should be performed.

Most posterior segment injuries can be ruled out with a dilated funduscopic examination.

The physical findings may involve only periorbital edema and ecchymosis; however, more severe cases may demonstrate limited vertical movement, enophthalmos, ptosis, and possibly proptosis.

Unusually severe orbital edema may be associated with more severe fractures and can cause proptosis. Once the edema has subsided (usually 1-2 wk), enophthalmos may be present.

Limited vertical movement may be due to entrapment of the perimuscular fascia of the inferior rectus in the fracture site. However, traumatic palsy of the third nerve branch to the inferior rectus also may cause decreased extraocular movements. If a question exists, forced duction testing may differentiate between the two conditions.

Hertel exophthalmometry may demonstrate either proptosis or enophthalmos and should be documented.

Causes

In a study of orbital fractures in an urban population, 70% of the fractures were due to assault with a blunt object (eg, fist, baseball bat), and 13% occurred due to a motor vehicle accident, usually involving striking the dashboard. Falls accounted for 10%, and gunshot wounds contributed to 6% of orbital floor fractures.

Workup